Ann Thorac Surg 2009;87:623-625. doi:10.1016/j.athoracsur.2008.06.080
© 2009 The Society of Thoracic Surgeons
Case Reports
Entire Stent Grafting of the Thoracoabdominal Aorta in a Renal Transplant Recipient Subsequent to Extra-Anatomical Bypasses of the Main Abdominal Vessels
John Kokotsakis, MDa,
Ioannis Kaskarelis, MDb,
Maria Koukoulaki, MD, MPhilc,*,
Thanos Athanasiou, MDa,
Elian Skouteli, MDa,
Vassilios Vougas, MDc,
Achilleas Lioulias, MDa,
Spiros Drakopoulos, MDc
a Second Cardiac Surgical Department, Evangelismos General Hospital of Athens, Athens, Greece
b Department of Radiology, Interventional Radiology Unit, Evangelismos General Hospital of Athens, Athens, Greece
c Transplant Unit, Evangelismos General Hospital of Athens, Athens, Greece
Accepted for publication June 27, 2008.
* Address correspondence to Dr Koukoulaki, Transplant Unit, Evangelismos General Hospital of Athens, 45-47 Ipsilantou St, Athens, 10676, Greece (Email: mkoukoulaki{at}gmail.com).
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Abstract
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We present a complex case of a renal transplant recipient with ruptured suprarenal abdominal aortic aneurysm who had previously undergone endovascular repair of descending thoracic and abdominal aortic aneurysm. This patient was treated successfully combining extra-anatomical bypasses of main abdominal arteries and subsequent endovascular stent grafting covering the entire thoracoabdominal aorta.
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Introduction
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Rupture of abdominal aortic aneurysm (AAA) is an acute condition that entails a high mortality rate [1]. Surgical management of the ruptured AAA in renal transplant recipients is more challenging because additional considerations are required to preserve renal graft perfusion.
We present a complex case of a renal transplant recipient with ruptured suprarenal AAA, who had previously undergone endovascular repair of a descending thoracic and AAA. This patient was treated successfully combining extra-anatomical bypasses of the main abdominal arteries and subsequent endovascular stent grafting of the entire thoracoabdominal aorta.
A 73-year-old man with end-stage renal disease received a cadaveric renal allograft 3 years ago. Routine pre-transplantation vascular assessment with ultrasonography demonstrated an aneurysmatic expansion of an abdominal aorta (4.4 cm in diameter), which was discussed in our multidisciplinary team and was considered low risk for rupture and marginal size for reconstruction. For this reason, the decision was undertaken that no intervention be considered prior to renal transplantation.
On post-transplantation day 9, he suddenly experienced acute abdominal pain with reflection to his back and was diagnosed with ruptured AAA that extended from the native renal arteries down to the common iliac arteries. The ruptured aneurysm was successfully repaired with endovascular placement of a bifurcated stent-graft as has been previously reported [2]. A year later, an aneurysmatic, descending thoracic aorta was identified, which was also repaired with stent grafting.
After an uneventful period, he revisited the renal transplant outpatient clinic with symptoms of abdominal pain and was admitted to renal transplant unit. A computed tomographic scan revealed a suprarenal AAA (with a diameter of 9.5 cm) presenting a leak at the site of superior mesenteric artery (Fig 1). The patient remained hemodynamically stable (blood pressure, 140/90 mm Hg; heart rate, 85 beats/min), but hematocrit gradually declined to 27%, suggesting uncontrolled leak from the ruptured aneurysm. A therapeutic approach was determined upon multidisciplinary discussion involving interventional radiology, the cardiovascular team, and the renal team. A "hybrid procedure" was decided in two steps, including revascularization of the visceral arteries (ie, hepatic and superior mesenteric arteries) and subsequent endovascular stent grafting of the entire thoracoabdominal aorta. Through a midline laparotomy, two extra-anatomic bypasses were performed in an end-to-side fashion from the right external iliac artery to the superior mesenteric and common hepatic arteries, respectively, with prosthetic grafts (6 mm Gore-Tex [W. L. Gore & Assoc, Flagstaff, AZ]). The celiac axis and proximal superior mesenteric artery were ligated to prevent a type II endoleak. One day later, a digital angiography was performed, which showed a leak at the site of the superior mesenteric artery (Fig 2A). A stent-graft Relay (diameter, 36 mm; length, 150 mm [Bolton Medical, Sunrise, FL]) was inserted through the right femoral artery (contralateral to transplantation site) and was successfully deployed in the suprarenal aorta, bridging the previously placed stent-grafts. The completion angiogram showed exclusion of the aneurysm sac and patency of the Gore-Tex grafts (W. L. Gore & Assoc) (Fig 2B). Spinal fluid drainage was not performed due to the persistent coagulopathy profile, despite our effort to reverse it by transfusion of fresh frozen plasma and platelets preoperatively.
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Fig 1. (A) Computed tomographic scan showing ruptured suprarenal abdominal aortic aneurysm at the origin of superior mesenteric artery (arrow) and thrombus (arrowheads). (B) Computed tomographic scan shows normal size renal graft (arrow) and metallic stents in iliac vessels (arrowheads).
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Fig 2. (A) Angiographic scan shows patency of extra-anatomic bypasses from right external iliac artery to superior mesenteric and common hepatic artery. (B) Endovascular stent along the thoracoabdominal aorta.
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The procedural time was two hours and nonionic contrast medium was used. Renal graft function prior to hospital admission was normal (serum creatinine, 1.4 mg/dL; estimated glomerular filtration rate, 48.36 mL/min/1.73m2). The recipient required three sessions of hemodialysis after the interventional procedures to re-establish sufficient diuresis and renal function. Computed tomography was performed 10 days later, and the scan showed exclusion of the ruptured AAA (Fig 3). No evidence of spinal cord injury or mesenteric ischemia was evident during the postoperative period. The patient was discharged after 27 days of hospitalization with slightly impaired renal graft function (serum creatinine, 2.9 mg/dL; estimated glomerular filtration rate, 23.35 mL/min/1.73m2).
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Fig 3. Computed tomographic scan 10 days after endovascular repair showing exclusion of aneurysm at the origin of superior mesenteric artery.
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Comment
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Renal transplant recipients present certain predisposition to aneurysm formation due to atherosclerosis and hypertension. There is an increased risk of postoperative complications after open surgical repair of thoraco-abdominal aortic aneurysm in these patients due to associated significant comorbidities. Endovascular repair of AAA was successfully performed in 1991 by Parodi and colleagues [3]. Eventually it was established not only as a safe alternative but also as a treatment of choice in high-risk patients [4]. In recent years, endovascular repair of AAA in renal transplant recipients is gaining credit because it overcomes the problem of allograft perfusion [5].
In our case, it is apparent that surgical repair was not selected for two reasons: (1) primarily because of pre-existing stents in the aorta and (2) because of the necessity to maintain renal graft perfusion. It was decided that the aortic stent-graft should be placed to exclude the entire aneurysmatic thoracoabdominal aorta. Perfusion of vital organs could only be preserved by extra-anatomic visceral revascularization.
Two-staged hybrid techniques of open retrograde bypass revascularization and endovascular stent grafting have been used with favorable results in selected patients [6]. We believe that this is the first report in the literature of successful hybrid procedure for the management of ruptured aneurysm in a renal transplant recipient.
An important advantage of endovascular versus surgical repair is the minimization of invasiveness. During endovascular repair, the aorta is not clamped, and blood loss is less. However, patients treated with endovascular repair are expected to have complications in the long run as a result of graft failure, such as endoleak and graft migration, and follow-up is essential. The limited follow-up (less than 1 year) is a restriction of this report. Patients treated with open surgery may have more severe complications during and immediately after the procedure, such as bleeding, cardiac and pulmonary complications, and ischemia of the spinal cord and abdominal organs. The entire exclusion of the aneurysmatic aorta can be complicated by paraplegia in a rate that varies from 7% to 29%, which was not observed in our patient [7]. Open surgical repair can provoke spinal cord ischemia and paraplegia due to aortic cross clamping and perioperative hypotension. Further endovascular repair minimizes the visceral, liver, and renal allograft ischemia time resulting in lower mortality rates.
The hybrid approach can be an alternative to classic surgical repair of thoraco-abdominal aortic aneurysm in cases that had previously undergone endovascular stent grafting and renal transplantation offering the opportunity to preserve the functioning allograft.
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References
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- Kantonen I, Lepantalo M, Brommels M, Luther M, Salenius JP, Ylonen K. Mortality in ruptured abdominal aortic aneurysms. The Finnvasc Study Group. Eur J Vasc Endovasc Surg 1999;17:208-212.[Medline]
- Kaskarelis IS, Koukoulaki M, Lappas I, et al. Successful endovascular repair of ruptured abdominal aortic aneurysm in a renal transplant recipient Cardiovasc Intervent Radiol 2006;29:279-283.[Medline]
- Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms Ann Vasc Surg 1991;5:491-499.[Medline]
- Greenhalgh RM, Powell JT. Endovascular repair of abdominal aortic aneurysm New Engl J Med 2008;358:494-501.[Medline]
- Lepantalo M, Biancari F, Edgren J, Eklund B, Salmela K. Treatment options in the management of abdominal aortic aneurysm in patients with renal transplant Eur J Vasc Endovasc Surg 1999;18:176-178.[Medline]
- Black SA, Wolfe JH, Clark M, Hamady M, Cheshire NJ, Jenkins MP. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization J Vasc Surg 2006;43:1081-1089.[Medline]
- Safi HJ, Miller 3rd CC, Huynh TT, et al. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection Ann Surg 2003;238:372-381.[Medline]
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Abstract
Introduction
